Osteoporosis is a common disease that causes a thinning and weakening of the bones; It can affect people of any age. There are many factors that can cause a person to be at risk for developing the disease. It is important to know the risks so that you can be proactive in treatment and prevention of osteoporosis. Two types of exercise has been proven for optimal bone health: weight bearing and resistance exercise.
Objectives
Overview of Osteoporosis
Benefits of exercise and improving bone mineral density (BMD)
Physical therapist role in treating patients with osteoporosis
Evidence based research on exercise and improving BMD in osteoporotic patients
Additional resources for patients with osteoporosis
Background of Osteoporosis
Osteoporosis is a systemic skeletal disease in which bone mass is reduced, the microstructure of the bone is destroyed, and the risk of fracture increases. Approximately 30% of women and 10% of men older than 50 years of age suffer from the disease4. Risk factors for developing osteoporosis include genetic, nutritional, and behavioral. Genetic factors include female sex, a petite skeletal frame, and Caucasian or Asian ancestry. Low calcium or vitamin D intake, alcohol abuse, and high caffeine intake are nutritional factors, and sedentary lifestyle, aging, smoking, and low body weight are some of the behavioral risk factors. The most common cause of osteoporosis is the decrease in the female sex hormone, estrogen, which occurs following menopause. This results in bone resorption due to the rise in osteoclast activity from the loss of estrogen1.
Osteoporosis is diagnosed best through a specialized x-ray that measures bone density called DXA. Results are reported using T-scores and Z-scores:
T-score (compares BMD to healthy 30 year old adults)
T-score of -1.0 or above is normal bone density
T-score between -1 and -2.5 means you have low bone density or osteopenia, greater risk for fracture
T-score of -2.5 or below is a diagnosis of osteoporosis, greatest risk for fracture
Z-score (Compares BMD to those of same sex, weight, age) Used for those whose bone mass has not yet peaked, premenopausal women, and men older than 50.1
Physiology of Exercise and Improving BMD
It has been proven that physical activity makes muscles and bones stronger. Not only does physical activity maximize bone strength, but it also minimizes bone loss to prevent falls in elderly population3. When mechanical loads are applied to bone, this creates an increase in cell metabolism and collagen synthesis as the strain is transmitted to the bone cells1. In order for exercise to be effective and prevent or treat osteoporosis, it must produce a dynamic rather than a static load on the bone. This produces an osteogenic effect on the bone which increases bone density. Three important facts to remember to produce an osteogenic response3:
Exercise must be at high intensity to overload the skeletal system beyond normal conditions in order to stimulate a response
Exercise must be novel in order to stress bone in ways that are new and different from normal daily activities and
Exercise effects must be site specific3
The cycle of bone activation, resorption, and formation appears to take approximately 3 to 4 months; therefore, BMD changes should not be expected prior to that time frame1.
How can physical therapist impact treatment and prevention in osteoporotic patients?
Physical therapist play an important role in the treatment and prevention of osteoporosis including developing specific exercise programs to build bone, improve balance and education on posture, prevention of injury and adjusting patients environments to protect their bone health.
Several outcomes measures can help you determine if you patients are at risks for falls:
FRAX-Fracture Risk Assessment Tool: free, online-tool used to determine fracture risk and 10 year probability of major osteoporotic fracture; for patient education and referral.7,8
The combination of FRAX score and use of functional outcome measure for risk of falling could be strong justification for the need of PT intervention and reimbursement for services3 as well as improve the prediction of fracture risk and enhance the evaluation of patients with osteoporosis6.
Physical Activity Recommendations in Osteoporotic patients from Evidence Based Research
Elderly Individuals: Supervised, customized, high dosage activity including two or more strength, balance, flexibility, and endurance exercises, with highly challenging balance activities with progression of difficulty overtime.
Physical Activity including 2-4 hours of leisure time of physical activity or more than 4 hours of walking per week
Tai Chi
Multicomponent group exercise and individually prescribed multi component, home-based exercise
All have been proven to be effective in increasing bone density, reducing fall risk and fall rate as well improve QOL in elderly people living in community3,4,5.
Post-menopausal women: Exercise intervention including high intensity impact activities/high intensity resistance lifting: leg press, leg extension, HS curls, squats, back extension, upper extremity weight lifting that loads through wrist, combined protocols of jogging, with low impact exercise like climbing and walking 2,3,4,5.
3-5 times week/ 75-80% max heartrate
2-3x week 70-90% or 1 rep maximum, 2-3 sets
Walking, gentle aerobic exercise (low impact) protects against further bone loss (lumbar spine and hips)5.
Vigorous aerobic exercise, running increase bone mineral density (hip and lumbar spine) weight training (wrist, hips, lumbar spine)5.
Downey, Patrica A., Siegel, Micahel I. Bone Biology and the Clinical Implications for Osteoporosis. Physical Therapy Journal. 2006; 86:77-91
Palombaro, K. M., Black, J. D., Buchbinder, R., & Jette, D. U. (2013). Effectiveness of exercise for managing osteoporosis in women postmenopause. Physical Therapy, 93(8), 1021-5. Retrieved from http://search.proquest.com/docview/1444018205?accountid=15070
Perry, Susan B., Downey, Patricia A. (2011). Fracture Risk and Prevent: A Multidimensional Approach. Physical Therapy Journal, Januray 2012 edition, Volume 92, Number 1.
Schröder, G., Knauerhase, A., Kundt, G., & Schober, H. (2012). Effects of physical therapy on quality of life in osteoporosis patients - a randomized clinical trial. Health and Quality of Life Outcomes, 10, 101. doi:http://dx.doi.org/10.1186/1477-7525-10-101
Todd, J.A, Robinson, R.J. (2003) Osteoporosis and exercise. Postgraduate Medical Journal; June 2003; 79, 932; ProQuest Central pg 320
Unnanuntana, Aasis et al. “The Assessment of Fracture Risk.” The Journal of Bone and Joint Surgery. American volume. 92.3 (2010): 743–753. PMC. Web. 8 July 2015.
Objectives
Background of Osteoporosis
Osteoporosis is a systemic skeletal disease in which bone mass is reduced, the microstructure of the bone is destroyed, and the risk of fracture increases. Approximately 30% of women and 10% of men older than 50 years of age suffer from the disease4. Risk factors for developing osteoporosis include genetic, nutritional, and behavioral. Genetic factors include female sex, a petite skeletal frame, and Caucasian or Asian ancestry. Low calcium or vitamin D intake, alcohol abuse, and high caffeine intake are nutritional factors, and sedentary lifestyle, aging, smoking, and low body weight are some of the behavioral risk factors. The most common cause of osteoporosis is the decrease in the female sex hormone, estrogen, which occurs following menopause. This results in bone resorption due to the rise in osteoclast activity from the loss of estrogen1.
Osteoporosis is diagnosed best through a specialized x-ray that measures bone density called DXA. Results are reported using T-scores and Z-scores:
Physiology of Exercise and Improving BMD
It has been proven that physical activity makes muscles and bones stronger. Not only does physical activity maximize bone strength, but it also minimizes bone loss to prevent falls in elderly population3. When mechanical loads are applied to bone, this creates an increase in cell metabolism and collagen synthesis as the strain is transmitted to the bone cells1. In order for exercise to be effective and prevent or treat osteoporosis, it must produce a dynamic rather than a static load on the bone. This produces an osteogenic effect on the bone which increases bone density. Three important facts to remember to produce an osteogenic response3:
- Exercise must be at high intensity to overload the skeletal system beyond normal conditions in order to stimulate a response
- Exercise must be novel in order to stress bone in ways that are new and different from normal daily activities and
- Exercise effects must be site specific3
The cycle of bone activation, resorption, and formation appears to take approximately 3 to 4 months; therefore, BMD changes should not be expected prior to that time frame1.How can physical therapist impact treatment and prevention in osteoporotic patients?
Physical therapist play an important role in the treatment and prevention of osteoporosis including developing specific exercise programs to build bone, improve balance and education on posture, prevention of injury and adjusting patients environments to protect their bone health.
Several outcomes measures can help you determine if you patients are at risks for falls:
- mCTSIB: Fall risk in older adults (Geriatric)6
- Berg Balance Scale: Fall risk is community dwelling elderly6
- FRAX-Fracture Risk Assessment Tool: free, online-tool used to determine fracture risk and 10 year probability of major osteoporotic fracture; for patient education and referral.7,8
The combination of FRAX score and use of functional outcome measure for risk of falling could be strong justification for the need of PT intervention and reimbursement for services3 as well as improve the prediction of fracture risk and enhance the evaluation of patients with osteoporosis6.Physical Activity Recommendations in Osteoporotic patients from Evidence Based Research
Elderly Individuals: Supervised, customized, high dosage activity including two or more strength, balance, flexibility, and endurance exercises, with highly challenging balance activities with progression of difficulty overtime.
- Physical Activity including 2-4 hours of leisure time of physical activity or more than 4 hours of walking per week
- Tai Chi
- Multicomponent group exercise and individually prescribed multi component, home-based exercise
All have been proven to be effective in increasing bone density, reducing fall risk and fall rate as well improve QOL in elderly people living in community3,4,5.Post-menopausal women: Exercise intervention including high intensity impact activities/high intensity resistance lifting: leg press, leg extension, HS curls, squats, back extension, upper extremity weight lifting that loads through wrist, combined protocols of jogging, with low impact exercise like climbing and walking 2,3,4,5.
- 3-5 times week/ 75-80% max heartrate
- 2-3x week 70-90% or 1 rep maximum, 2-3 sets
Walking, gentle aerobic exercise (low impact) protects against further bone loss (lumbar spine and hips)5.Vigorous aerobic exercise, running increase bone mineral density (hip and lumbar spine) weight training (wrist, hips, lumbar spine)5.
Additional Resources
National Osteoporosis Foundation: http://nof.org/
National Institutes of Health: Osteoporosis and related bone disease National resource center: http://www.niams.nih.gov/health_info/bone/osteoporosis/
MoveForwardPT: http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=b5e09439-77a8-497d-b8d9-b5250de60544#.VZ070flViko
Pocket Guide for PT’s: Physical Fitness and Falls Risk Reduction Based on Best Available Evidence http://www.apta.org/PFSP/ (APTA Membership required for access)
References